Pulseless Electrical Activity Cardiac Arrest

Audience This simulation-based scenario is appropriate for senior level emergency medicine residents. Introduction Pulseless electrical activity (PEA) accounts for up to 25% of sudden cardiac arrest;1 therefore the ability to recognize and care for this condition is an essential skill of emergency medicine physicians. Management of PEA arrest in the emergency department centers on Advanced Cardiac Life Support (ACLS) algorithms and the identification and treatment of potentially reversible causes. Massive pulmonary embolism (PE) is one of several causes of PEA cardiac arrest.2 However, diagnosis by CT-angiographic or nuclear imaging may not be obtainable in the hemodynamically unstable patient, requiring physicians to have a high index of suspicion. Systemic thrombolytic therapy is indicated in cardiac arrest due to known or presumed massive pulmonary embolism.3,4,5 Educational Objectives After competing this simulation-based session, the learner will be able to: Identify PEA arrest Review the ACLS commonly recognized PEA arrest etiologies via the H &T mnemonic Review and discuss the risks and benefits of tissue plasminogen activator (tPA) for massive PE Educational Methods This is a high-fidelity simulation that allows learners to evaluate and treat a PEA arrest secondary to massive PE in a safe environment. The learners will demonstrate their ability to recognize a PEA arrest, sort through possible etiologies, and demonstrate treatment of a massive PE with tPA. Debriefing will focus on diagnosis and management of the PEA arrest. Research Methods This case was piloted with 12 PGY-2 and PGY-3 residents. Group and individual debriefing occurred post-case. Results Post-simulation feedback from the faculty suggested two potential issues. First was fidelity, which we increased by using our ultrasound simulator. Second, the elevated presenting glucose with lactic acidosis could be a poor cue, leading some towards diabetic ketoacidosis (DKA). Discussion Learners felt more confident about running a PEA arrest. The simulation improved resident awareness of the value of point of care ultrasound (POCUS) in cardiac arrest. It also clarified the dosing of tPA in massive PE. Faculty felt simulating the actual US without breaking simulation would be more challenging without our US simulator. Although there was concern about results pointing towards possible DKA, this did not occur in any of the pilot simulations. The presenting glucose was reduced to make this less likely in future simulations. Topics Pulseless electrical activity (PEA), syncope, cardiac arrest, Hs and Ts from ACLS PEA instruction, tPA for massive PE, critical care medicine, simulation.

. Wan S, Quinlan D, Agnelli G, Eikelboom J. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials.

Case Description & Diagnosis (short synopsis):
Patient is a 40-year-old female brought in by EMS for a suspected syncopal episode after being found unconscious. She was awake and alert at time of EMS arrival but grew increasingly agitated. Paramedics have grown frustrated with her agitation, and her agitation continues upon arrival. She will complain of pain but will not localize and grows progressively distressed. The patient is unable to provide further detailed history, though her family confirms she began birth control in the last few months. She is negative for any other PE risk factors. While in the emergency department she grows increasingly tachypneic, tachycardic, and hypoxic, eventually requiring intubation. Following intubation her blood pressure and pulse are lost and she has a PEA arrest. Participants will need to consider possible etiologies for PEA arrest and implement a treatment strategy. If Hs & Ts are not fully discussed, learners will be verbally prompted by an embedded participant. Participants should establish the diagnosis of massive PE. Ultrasound (US) confirms dilated right ventricle, and participants should discuss the risk and benefits of tPA administration. Embedded participant will prompt the tPA discussion if necessary as well. Participants should then administer tPA, after which they will obtain return of spontaneous circulation (ROSC). Participants may then order computed tomography (CT), which reveals massive PE with bilateral segmental emboli. If participants fail to follow ACLS guidelines, establish the diagnosis of PE, or fail to administer tPA, the patient will proceed to asystole and death. Background and brief information: The scenario occurs in the emergency department at a tertiary care center. The patient is a 40-year-old female brought in by EMS for a suspected syncopal episode. The patient was found unconscious on bathroom floor at work by coworker. She was awake and alert at time of EMS arrival but grew increasingly agitated. Paramedics have grown frustrated with her agitation and refusal to cooperate with their assessment, and this continues on their arrival. She will complain of pain but will not localize and grows progressively distressed in the emergency department. The patient is unable to provide further detailed history, though her family will confirm that she began birth control in the last few months. She is negative for any other PE risk factors. While in the emergency department she grows increasingly tachypneic, tachycardic, and hypoxic, eventually requiring intubation. Following intubation her blood pressure and pulse are lost and she has a PEA arrest. Participants will need to consider possible etiologies for PEA arrest and implement a treatment strategy. If Hs & Ts are not fully discussed, learners will be verbally prompted by an embedded participant.
Initial presentation: Patient is brought in by EMS, who appear frustrated with the patient's lack of cooperation. She is alert, but in severe distress. She is oriented to self but otherwise minimally able to cooperate with history and exam. She is tachypneic and complains of pain and discomfort but cannot localize cause of her distress. She is very agitated, attempting to remove her gown and oxygen mask.
How the scenario unfolds: This patient has a massive PE. Paramedics will be present at the beginning of the case and will give her presenting history in a calm, dismissive tone. The participants should recognize that the patient is sicker than this report suggests and establish IV access, place the patient on the monitor, and apply oxygen. Laboratory and bedside imaging (CXR/US) may be requested at this time, but participants will be told the patient is too unstable for CT. Other than the agitation, tachycardia, and respiratory distress, the exam is

INSTRUCTOR MATERIALS
eturn: Calibri Size 10 Sembroski E, et al. Pulseless Electrical Activity Cardiac Arrest. JETem 2020. 5(1):S1-25. https://doi.org/10.21980/J8Z055 7 largely unremarkable. The patient quickly grows increasingly distressed, tachypneic and tachycardic and eventually hypoxic. If the participants do not elect to intubate early, the patient will become progressively hypoxic until this decision is reached (if they attempt to place BiPAP, they will be told that the patient tears it off). Following intubation, the patient has a rapid decline in blood pressure, eventually resulting in loss of pulses and a PEA arrest. The participants should then verbalize Hs and Ts or another approach to determining reversible causes of PEA arrest. The patient will remain in PEA arrest as long as the participants follow ACLS. The participants should identify a massive PE as the most likely cause of the arrest and administer tPA (100 mg IV over two hours). The patient will then have ROSC. Bedside US should be available and if asked for will show right ventricular dilation. Following ROSC and stabilization, if the participants request a CT this will show PE with bilateral segmental emboli. The learners should then discuss with the ICU for admission. General Appearance: 40-year-old female who appears agitated, mottled and dyspneic.
Primary Survey: • Airway: moaning and making incomprehensible noises but not able to state her name when asked • Breathing: rather tachypneic, increased work of breathing • Circulation: pale, cool extremities; no palpable distal pulses History: • History of present illness: 40-year-old female presents in acute respiratory distress. Per EMS she was found on the bathroom floor by a family member after a loss of consciousness. Initially, they were called for a possible seizure, but on arrival, the patient was agitated and combative. She reports pain and severe trouble breathing but is unable to localize her pain. Her family member arrives and provides history that the patient is on birth control. A: Patient is alert, oriented to self, protecting her airway, speaking and moaning in pain. B: Tachypneic, breathing in high 20s. In severe respiratory distress but with clear lung sounds. C: She is tachycardic, pale, mottled, but with adequate initial blood pressure.
When placed on supplemental O2 nonrebreather (NRB) patient is adamant it be removed, states "I can't breathe." She is able to say her name, but otherwise does not answer questions. Only states "it hurts" and "I can't breathe." Does not localize pain when asked. Participants may need to be prompted for this discussion while progressing through ACLS. Disparity between patient's presentation of tachypnea and respiratory acidosis/hypoxia should be discussed. Patient's family member may be interviewed and will confirm that she is on birth control.